Short Term Disability Insurance

Transcription

1 Short Term Disability Insurance This subsection summarizes the group Short Term Disability Insurance plan available through PEBB. It is a summary only. For full details, see the Certificate of Insurance on the PEBB Website. The controlling provisions of the plan are in the group policy issued by Standard Insurance Company (The Standard). The information presented in this summary and in the Certificate of Insurance in no way modifies that group policy or the insurance coverage. Eligibility for Coverage To be eligible for Optional Short Term Disability (STD) Insurance, you must be an active employee of the state of Oregon who is actively at work and who meets the terms of eligibility in PEBB Administrative Rules. You are not eligible if you are: a seasonal or intermittent employee; an employee scheduled to work fewer than 90 days; a temporary employee; a full-time member of the armed forces of any country. Effective Date of Coverage Your STD Insurance becomes effective: The first day of the calendar month following the date you enroll, if you enroll within 30 days after becoming an eligible employee January 1 of the following year if you enroll during the annual open enrollment period The first day of the calendar month following the date you enroll if you enroll within 30, days following a qualified status change (as determined by your employer). You pay the entire cost of coverage. Actively at Work Requirement You must meet the active work requirement for any coverage or increase in coverage to become effective. If you are incapable of active work because of physical disease, injury, pregnancy or mental disorder on the day before the scheduled effective date of your insurance or an increase in your insurance, your insurance or increase will not become effective until the day after you complete one full day of active work as an eligible employee. Active work and actively at work mean performing the material duties of your own occupation at your employer's usual place of business. You will also meet the active work requirement if: 1. You were absent from active work because of a regularly scheduled day off, holiday, or vacation day; 2. You were actively at work on your last scheduled work day before the date of your absence; and 3. You were capable of active work. Benefit Amount The Standard pays benefits at the end of each week in which you qualify. The weekly amount is 60 percent of the first $2,770 of your weekly predisability earnings, reduced by deductible income. The maximum weekly benefit, before reduction by deductible income, is $1,662. Members who qualify for disability benefit payments can choose to use accrued leave and receive a reduced benefit payment (minimum of $25 per week); or they can elect to receive the full benefit payment without using accrued sick leave. 48

2 If you are disabled for less than a full week, you will be paid one-seventh of the benefit for each day of disability. Benefit Waiting Period If The Standard approves your claim, it will pay benefits only after the benefit waiting period. The benefit waiting period is a specified number of days for which you must remain continuously disabled. This is seven days if the disability is caused by physical disease, pregnancy or mental disorder. There is no benefit waiting period if the disability is caused by accidental injury. However, if your disability begins while you are scheduled to be away from work under the terms of your employment, your benefit waiting period is the longer of the date determined above and the period ending on the day before you were scheduled to return to work. Maximum Benefit Period Benefits may continue for any one period of disability up to the maximum benefit period of 13 weeks, unless the preexisting condition limitation applies. In that case, the maximum benefit period is four weeks. If you are eligible to receive benefits under any other disability plan, your STD benefits will end when the other disability benefits become payable. This applies even if you become eligible for the other benefits before the end of the STD maximum benefit period. Definition of Disability The Standard terms you disabled if, as a result of physical disease, injury, pregnancy or mental disorder, you are unable to perform with reasonable continuity the material duties of your own occupation. The Standard terms you partially disabled if you work for the state of Oregon but are unable to earn more than 80 percent of your predisability earnings. You are no longer disabled when your earnings from any occupation exceed 80 percent of your predisability earnings. Return to Work Incentive You may work for the state of Oregon during the benefit waiting period and while you are receiving benefits. The Standard will reduce your weekly benefit amount to the extent your earnings exceed 100 percent of your predisability earnings when added to your gross benefit. Reasonable Accommodation Benefit If you return to work in any occupation for the state of Oregon through the state s workplace accommodation, The Standard will reimburse your employer for the incurred expenses to an amount agreed upon in advance and in writing by The Standard and your employer. Temporary Recovery If you temporarily recover and then become disabled again from the same cause or causes after benefits are payable, and the recovery period does not exceed 14 days, The Standard will Not impose a new benefit waiting period 49

3 Resume paying benefits as if no break in coverage had occurred Use the same predisability earnings to determine your benefit Reduce the maximum benefit period by the previous period or periods of disability. Predisability Earnings Predisability earnings are your weekly earnings from the state of Oregon in effect on the last full day of active work. They include: Salary Grant assistance wages Stipends Contributions you make through a salary reduction agreement with your employer to an IRC Section 401(k), 403(b), 408(k), 408(p) or 457 deferred compensation arrangement, or an executive nonqualified deferred compensation arrangement Amounts contributed to fringe benefits according to salary reduction agreements under an IRC Section 125 plan Predisability earnings exclude: bonuses; overtime pay; your employer s contribution to a deferred compensation arrangement or pension plan; state-paid benefit amounts in excess of your premiums for medical insurance, dental insurance and the first $50,000 of group life insurance; or any other extra compensation. If you are paid hourly, predisability earnings are determined by multiplying your hourly pay rate by the average number of hours you worked per week during the preceding 13 weeks (or during your period of employment if less than 13 weeks), but not more than 40 hours. Deductible Income The Standard considers the following deductible income and deducts any amounts from your benefit: Work earnings, as described in the Definition of Disability, above Benefits you are eligible to receive under any other short term disability plan that, when added to your benefit under this plan, exceed 75 percent of your predisability earnings Amounts received by compromise, settlement or other method as a result of a claim for the above, whether disputed or undisputed. Sick pay (including donated leave) paid to you by your Employer Exclusions and Limitations You are not covered for a disability Caused or contributed to by an intentionally self-inflicted injury, while sane or insane Arising out of or in the course of any employment for wage or profit. No benefits will be paid for any period you are Not under the on-going care of a physician in the appropriate specialty, as determined by The Standard Eligible to receive workers compensation or similar benefits 50

4 Working for any employer other than the state of Oregon or are self-employed Confined for any reason in a penal or correctional institution. Pre-existing Condition: The Standard limits your maximum benefit period to four weeks if your disability is caused or contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition. A preexisting condition is a mental or physical condition for which, during the 90 days immediately preceding the date you became insured, you consulted a physician or other licensed medical professional, received medical treatment, services or advice, underwent diagnostic procedures (including self-administered procedures), or took prescribed drugs or medications. The Standard will not apply this limitation to a disability that begins after you have been insured under the group policy for 12 months and have been actively at work for at least one day after those 12 months. When Benefits End Benefits end on the earliest of The date you are no longer disabled The end of the maximum benefit period The date you die The date you begin working for any employer other than the state of Oregon, or are self-employed The date long term disability benefits become payable to you The date benefits become payable to you under any other disability insurance plan under which you become insured through employment during a period of temporary recovery The date you fail to provide proof of continued disability and entitlement to benefits. When Coverage Ends This coverage ends automatically on the earliest of the following dates: End of the period for which a premium was paid for your coverage You cease to be eligible under PEBB Administrative Rules You become a full-time member of the armed forces The group policy ends. Claims To make a claim, use the information provided on this link: The Standard may Investigate your claim at any time Have you examined at reasonable intervals by specialists of their choice Deny or suspend benefits if you fail to attend an examination or cooperate with the examiner. 51

5 Initial Claims Decision: State of Oregon The Standard will evaluate your claim promptly after you file it, and within 30 days after receipt of your claim they will send written notification of having received it. Within 45 days after receiving your claim they will send you: (a) a written decision on your claim; or (b) a notice that they are extending the period to decide your claim for 30 days. They will render a written decision or request an extension no later than 30 days after receipt of proof of loss. Before the end of this extension period they will send you: (a) a written decision on your claim; or (b) a notice that they are extending the period to decide your claim for an additional 30 days. If an extension is due to your failure to provide information necessary to decide the claim, the extended time period for deciding your claim will not begin until you provide the information or otherwise respond. If The Standard extends the period to decide your claim, they will notify you of the following: (a) the reasons for the extension; (b) when they expect to decide your claim; (c) an explanation of the standards on which entitlement to benefits is based; (d) the unresolved issues preventing a decision; and (e) any additional information they need to resolve those issues. If they request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, they may decide your claim based on the information they have received. If The Standard denies any part of your claim, you will receive a written notice of denial containing: The reasons for the decision. Reference to the parts of the group policy on which the decision is based. A description of any additional information needed to support your claim. Information concerning your right to a review of the decision. Review Procedure: If all or part of a claim is denied, you may request a review from The Standard. You must request a review in writing within 180 days after receiving notice of the denial. You may send The Standard written comments or other items to support your claim. You may review and receive copies of any non-privileged information that is relevant to your request for review. There will be no charge for such copies. You may request the names of medical or vocational experts who provided advice to The Standard about your claim. The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based on a medical judgment, the person conducting the review will consult with a qualified health care professional. This health care professional will be someone other than the person who made the original medical judgment and will not be subordinate to that person. The Standard s review will include any written comments or other items you submit to support your claim. The Standard will review your claim promptly after receiving your request. Within 45 days after receiving your request for review they will send you: (a) a written decision on review; or (b) a notice that they are extending the review period for 45 days. If the extension is due to your failure to provide information necessary to decide the claim 52

6 on review, the extended time period for review of your claim will not begin until you provide the information or otherwise respond. If they extend the review period, The Standard will notify you of the following: (a) the reasons for the extension; (b) when they expect to decide your claim on review; and (c) any additional information they need to decide your claim. If they request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, The Standard may conclude their review of your claim based on the information they have received. If they deny any part of your claim on review, you will receive a written notice of denial containing: The reasons for the decision. Reference to the parts of the group policy on which the decision is based. Information concerning your right to receive, free of charge, copies of non-privileged documents and records relevant to your claim. Premium Rates The premium rate is times your gross monthly salary. Example: Your gross monthly salary is $3,234. $3,234 times equals $17.46, the premium that is deducted from your salary. 53